HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, “treatment as prevention” for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

/pdf/combination-prevention-new-hope-for-stopping-the-epidemic-2b65won1et.pdf

Combination Prevention: New Hope for Stopping the Epidemic

Introduction: Increasing access to contraception among women who enter the health system for HIV care is crucial to help them achieve their fertility intentions and reduce vertical transmission of HIV. Identifying intervention strategies that contribute to effective family planning/HIV service integration and synthesizing lessons for future integration programming and research is important to move the field forward. Methods: Using a standard review methodology we searched for articles in the peer-reviewed literature published between January 2008 and August 2013 that addressed the integration of family planning interventions into HIV service settings. Eligible studies were assessed in terms of methodological rigor; documented outcomes; and reported process and cost data. Results: Twelve studies met our inclusion criteria. Eight studies documented significant increases in contraceptive use by HIV service clients and three reported significant increases in completed referrals from HIV services to family planning clinics. The outcomes of the seven studies implemented in public sector facilities were more modest than the five studies embedded in clinical trials. Process evaluation measures for some of the studies indicated weak implementation of the intervention as intended. The average rigor score was low 3.4 out of 9. Conclusion: Our review reveals an expanding evidence base for integrated family planning/HIV service delivery innovations. However the modest observed effect under typical settings and the evidence of weak intervention implementation emphasize the need for stronger programmatic efforts and implementation research to address the health system obstacles to integrating these two essential services.

Integration of family planning into HIV services: a synthesis of recent evidence.

Men's limited understanding of family planning (FP) and harmful cultural gender norms pose obstacles to women's FP use. Thirty-two model men called 'Emanzis' were recruited from the community in Kabale, Uganda to lead men from their peer group through a 10-session curriculum designed to transform gender norms and motivate men to engage in FP and HIV services. Cross-sectional surveys were conducted before (n = 1251) and after (n = 1122) implementation. The Gender Equitable Men (GEM) Scale was used to assess the effect on gender attitudes. The intervention achieved negligible changes in responses to GEM items. Improvements in some gender-influenced health-seeking behaviours and practices in men were noted, specifically in visiting health facilities, HIV testing, and condom use. For future application, the intervention should be adapted to require higher peer educator qualifications, longer intervention duration, and more frequent supervision. Practical guidance is needed on where to direct investments in gender-transformative approaches for maximum impact.

Evaluation of a male engagement intervention to transform gender norms and improve family planning and HIV service uptake in Kabale, Uganda

Objective: To describe predictors of contraceptive method discontinuation and switching behaviours among HIV-positive couples receiving couples’ voluntary HIV counselling and testing services in Lusaka Zambia. Design: Couples were randomized in a factorial design to two-family planning educational intervention videos received comprehensive family planning services and were assessed every 3 months for contraceptive initiation discontinuation and switching. Methods: We modelled factors associated with contraceptive method upgrading and downgrading via multivariate Andersen–Gill models. Results: Most women continued the initial method selected after randomization. The highest rates of discontinuation/switching were observed for injectable contraceptive and intrauterine device users. Time to discontinuing the more effective contraceptive methods or downgrading to oral contraceptives or condoms was associated with the women’s younger age desire for more children within the next year heavy menstrual bleeding bleeding between periods and cystitis/dysuria. Health concerns among women about contraceptive implants and male partners not wanting more children were associated with upgrading from oral contraceptives or condoms. HIV status of the woman or the couple was not predictive of switching or stopping. Conclusion: We found complicated patterns of contraceptive use. The predictors of contraception switching indicate that interventions targeted to younger couples that address common contraception-related misconceptions could improve effective family planning utilization. We recommend these findings be used to increase the uptake and continuation of contraception especially long-acting reversible contraceptive (LARC) methods and that fertility goal based LARC-focused family planning be offered as an integral part of HIV prevention services.

/pdf/contraceptive-discontinuation-and-switching-among-couples-o25deevk18.pdf

Contraceptive discontinuation and switching among couples receiving integrated HIV and family planning services in Lusaka, Zambia

Tremendous gains have been made in the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Ambitious goals for the “virtual elimination” of pediatric HIV appear increasingly feasible, driven by new scientific advances, forward-thinking health policy, and substantial donor investment. To fulfill this promise, however, rapid and effective implementation of evidence-based practices must be brought to scale across a diversity of settings. The discipline of implementation research can facilitate this translation from policy into practice; however, to date, its core principles and frameworks have been inconsistently applied in the field. We reviewed the recent developments in implementation research across each of the four “prongs” of a comprehensive PMTCT approach. While significant progress continues to be made, a greater emphasis on context, fidelity, and scalability—in the design and dissemination of study results—would greatly enhance current efforts and provide the necessary foundation for future evidence-based programs.

Implementation Research for the Prevention of Mother-to-Child HIV Transmission in Sub-Saharan Africa: Existing Evidence, Current Gaps, and New Opportunities.

Fertility goal-based counseling increases contraceptive implant and IUD use in HIV discordant couples in Rwanda and Zambia

Background: HIV-discordant heterosexual couples are faced with the dual challenge of preventing sexual HIV transmission and unplanned pregnancies with the attendant risk of perinatal HIV transmission. Our aim was to examine uptake of two long-acting reversible contraceptive (LARC) methods — intrauterine devices (IUD) and hormonal implants — among HIV-discordant couples in Rwanda and Zambia. Study Design: Women were interviewed alone or with their partner during routine cohort study follow-up visits to ascertain fertility goals; those not pregnant, not infertile, not already using LARC, and wishing to limit or delay fertility for ≥3 years were counseled on LARC methods and offered an IUD or implant on-site. Results: Among 409 fertile HIV-discordant Rwandan women interviewed (126 alone, 283 with partners), 365 (89%) were counseled about LARC methods, and 130 (36%) adopted a method (100 implant, 30 IUD). Of 787 fertile Zambian women interviewed (457 alone, 330 with partners), 528 (67%) received LARC counseling, of whom 177 (34%) adopted a method (139 implant, 38 IUD). In both countries, a woman's younger age was predictive of LARC uptake. LARC users reported fewer episodes of unprotected sex than couples using only condoms. Conclusions: Integrated fertility goal-based family planning counseling and access to LARC methods with reinforcement of dual-method use prompted uptake of IUDs and implants and reduced unprotected sex among HIV-discordant couples in two African capital cities.

Original research article Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia ☆

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Fertility goal-based counseling increases contraceptive implant and IUD use in HIV discordant couples in Rwanda and Zambia

Original research article Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia ☆